Deep in the hills, far from towns and hospitals or even a village doctor, the parish nurse for years was often the only health-care provider that folks in the back-country ever saw.

For many rural and poor residents of South Carolina, access is still an issue. They must travel great distances to get health care, if they can afford it, wait to see a busy provider, stand in line at a clinic, or go without.

And with the growing shortage of primary care physicians, coupled with the increasing number of people eligible for insurance beginning in 2014 as a result of the Affordable Care Act, access is expected to become a problem for many more.

Today’s nurse practitioners say they are helping to fill the gap. And some advocates say they could do even more if laws limiting their scope of practice were changed to give them more autonomy and allow them to provide more services.

But opposition from the American Medical Association and other physician groups could stand in their way.

More than 50 million Americans live in areas without enough health-care providers, according to new research published in the journal Health Affairs.

In South Carolina, 42 of 46 counties are considered rural or underserved, Dr. Stephanie Burgess, associate dean for practice and clinical professor at the University of South Carolina College of Nursing, told GreenvilleOnline.com.

Burgess is chairman of the Advanced Practice Nursing Committee that last year produced a White Paper on the issue after the Institute of Medicine concluded nurses with advanced degrees should be allowed to practice to the full extent of their education and training.

The institute also called on the federal government, states and other entities to improve access to care by removing scope-of-practice barriers such as limiting prescribing authority and requiring that nurse practitioners work under physician supervision.

“Up to 800,000 South Carolina folks projected to enter the system in 2014 will clearly burgeon a system that is already not meeting the health-care needs of our citizens,” says Burgess. “South Carolina needs solutions, not roadblocks.”

On her own

Nurse practitioners and other registered nurses with advanced degrees provide many of the same services as primary care doctors, from physical exams and ordering tests to health screenings and prescribing certain medications. They work in physician offices, outpatient clinics, rural care centers and other health-care settings.

Donna Marling was a paramedic before earning an advanced degree from Clemson as a nurse practitioner in 2004 and worked in obstetrics, family medicine and emergency settings. But in September, she launched a solo practice when she opened Genesis Medical Care in Easley.

“I was very unhappy with corporate life, so I chose to step out on my own,” says Marling, a youthful 40-year-old with an open, engaging style. “This has been a hassle trying to set everything up, but ... having someone dictate how I could practice and treat patients and who I was allowed to see really troubled me.”

Nurse practitioners typically work in tandem with a doctor. But in South Carolina, they can practice independently as long as they have a supervising physician within 45 miles and telephone contact during open hours.

Marling says she usually sees her supervising physician every three months for chart review, and can call him for assistance when necessary.

But on a typical day, she’s conducting physicals, stitching up wounds, prescribing antibiotics, and managing diabetes, high blood pressure and other chronic illnesses. She supports removing barriers that keep her from providing additional care.

Among other impediments, according to the White Paper, nurse practitioners can’t order patient disability stickers, home care or durable medical equipment. They can’t get hospital privileges or place patients in hospice care. And some plans won’t allow them to enroll as providers.

Team leader

Dr. Bruce Snyder, president-elect of the South Carolina Medical Association and past president of the Greenville County Medical Society, says that while nurse practitioners are valued members of the health-care team, it’s important that team is led by a physician.

A nurse practitioner may not be able to judge whether a patient needs to be referred to a specialist, for example, he says.

“I would never try to treat neurosurgical patients or cardiac patients or cancer. That’s not my expertise,” he says. “But I may see patients who need that expertise and the additional training allows me to make that decision.”

At Paris View Family Practice in Greenville, Dr. Carolyn Fields relies on her nurse practitioner to help care for her patients.

“The NPs I’ve worked with are very bright people and hard workers and very capable with the training they’ve had. We make a good team,” she says.

“But ... if you have something that’s a bit unusual — and I find all the time I see things I’ve never seen in any textbook because patients don’t always present in standard ways — that if you don’t have that depth of knowledge, it might be hard to figure out what is best to do for that patient,” she adds. “And the NP may not recognize that something is significant. So I think a collaboration really works best.”

“With a shortage of both physicians and nurses in the U.S., increasing the responsibility of nurses beyond their education and training is not the answer to increasing access to care in rural areas,” AMA president Dr. Jeremy A. Lazarus told GreenvilleOnline.com.

“As the provision of health care in this country becomes more complex, a fully coordinated, quality-focused and patient-centered health care team will be the optimal means by which Americans will receive their health care,” he said. “To address the shortage issue and increase access to high-quality care for patients, the focus must remain on expanding the health care work force overall and getting health-care professionals in areas where shortages loom.”

Lazarus added that research shows that even in states where nurses practice independently, physicians and nurses work in the same urban areas.

And the American Academy of Family Physicians in a September report also said nurse practitioners shouldn’t be substituted for doctors to address the physician shortage because studies have shown the most efficient care is provided by teams of health professionals led by physicians.

“Creating a system in which some patients have access to only a nurse practitioner is endorsing two-tiered care,” said Dr. Roland Goertz, chairman of AAFP’s board of directors. “That doesn’t happen in the physician-led, patient-centered medical home, and we believe all Americans should have access to this quality of care.”

A growing need

But Angela Golden, president of the American Academy of Nurse Practitioners, says that doesn’t recognize the current realities in health care.

“As the United States implements historic changes to our health-care system and as the shortage of physicians continues to grow, NPs must be full participants in the initiatives emerging from all corners of our industry in order to best protect and preserve the health of our population,” she said.

Nationally, and in South Carolina, advance practice nurses must have at least a master’s degree and all graduate-level programs must be accredited and have a curriculum that meets national standards, as well as two years of clinical training, according to the White Paper.

And evidence shows advanced practice nurses “are safe providers, provide quality care, are cost effective, and deliver a high degree of patient satisfaction, even in independent roles,” that paper reports.

According to the Health Affairs research, a review of 26 studies found little difference in treatment practices, prescribing behavior and patient health status between nurse practitioners and physicians.

The research also revealed that patients of nurse practitioners were happier with their care.

Janice Hannah lives in Franklin, N.C., but decided to make Marling her primary care provider. The 52-year-old property manager says she came across her while visiting her parents in Pickens and makes the two-hour drive because, in addition to providing quality care, Marling is a good communicator, compassionate, and takes enough time with her.

“I went to the doctor with my mother, and he said, ‘Your 15 minutes are up.’ You wait two hours to see a doctor and then he tells you your 15 minutes are up,” Hannah says. “She listens. She doesn’t rush you out. And if I have any problems, I can always call her.’

But Marling says nurse practitioners are seen by many in the medical establishment as a subcategory of providers.

“I suspect that’s part of the problem we’re having,” she says. “We’re like the pack mule that carries a load, but doesn’t get thanked for it.”

If she suspects a patient has a cardiac or orthopedic or other issue, Marling says she refers him to a specialist. And a complex patient is referred to an internist.

Studies show nurse practitioners do make appropriate referrals outside their practice limits, Burgess says. Furthermore, she says, they can manage up to 90 percent of the patients in a primary care practice and that the remainder, for instance someone with a breast mass, would have to be referred to a specialist by a primary care doctor as well.

Training and skills

Burgess says some physicians see expanding the nurse practitioner role as an encroachment on their territory. And Dr. Rosanne Pruitt, assistant dean and program director at Clemson’s School of Nursing, says most of today’s physicians came through a system where they are the captain of the ship and are intimidated by the idea of nurse practitioner autonomy.

But Snyder says it’s not a turf battle, it’s an issue of training and expertise.

“We do not think that nurse practitioner training is identical to, nor matches in scope of training, that of a physician,” he says. “But that in no way should imply that well-trained nurse practitioners cannot do many things as a member of the team led by a physician.”

In regions that need better access, nurse practitioners and other physician extenders should work closely with a doctor, Snyder says, though the doctor doesn’t have to be on site as long as there is ongoing communication that allows assistance when necessary.

But that argument is “self-serving rather than patient-centered,” says Dr. Gail Stuart, dean of the College of Nursing at the Medical University of South Carolina, which recently got a $250,000 grant from the BlueCross BlueShield of South Carolina Foundation to add 70 nurse practitioner students a year to double the number of advanced practice nurses they produce.

For instance, she says, under current law, a nurse practitioner can’t practice in a rural setting if there is no physician within 45 miles. And there aren’t enough physicians available to supervise the number of nurse practitioners practicing.

Noting South Carolina ranks 35th nationally in the number of nurse practitioners, BlueCross Foundation executive director Harvey Galloway said most nurse practitioner students stay in the state and often work in areas most in need of providers.

“This is a poor, rural state, and it also has a relatively small health care work force. And as the population ages, we’re going to need more people taking care of patients,” he says. “We’ve seen a decline in the number of primary care doctors in the state, particularly in some of the rural areas. And we believe that nurse practitioners are an answer to the shortage of primary care physicians in helping to take care of a needy population.”

Not enough doctors

Facing staggering medical school debt and low reimbursement compared to specialists, fewer doctors have been going into primary care. And proposals to address the shortage, including increased reimbursement and loan forgiveness, won’t result in enough of them to meet the demand, according to the nonprofit Center for Studying Health System Change.

There are about 300,000 primary care physicians in the United States now, and some 3,000 new ones are produced each year, the center reports. And the Affordable Care Act will mean another another 32 million people with insurance by 2019, which will increase the shortage of primary care physicians from 25,000 to 45,000 by 2020, according to the center.

And even if the supply grew by 20 percent, which the study authors called optimistic, only about 6,000 new primary care doctors would enter the work force by 2020.

So around the country, advocates are pushing for changes in the way primary care is delivered.

According to the Health Affairs research, 18 states and the District of Columbia allow “nurse practitioners to diagnose and treat patients and prescribe medications without a physician’s involvement, while 32 states required physician involvement to diagnose and treat or prescribe medications, or both.”

In the Palmetto State, the South Carolina Nurses Association, which supports increased autonomy for advanced practice nurses, and five other groups have formed a new coalition to ensure patients have access to “the quality, licensed health-care professionals of their choice.”

They are looking to break down barriers to the scope of practice, Burgess says, which might include autonomous practice.

Any solutions will require legislative changes to the Nurse Practice Act, but no bill has been drafted thus far, she says.

Snyder says it would be inappropriate to replace medical school with the training provided to a nurse practitioner by legislation or regulation.

A new model

With many practicing physicians expected to retire over the next decade and not enough doctors in the pipeline to replace them, there is pressure to redesign the health care delivery system, says Dr. Angelo Sinopoli, chief medical officer and vice president for clinical integration at Greenville Hospital System.

All providers should function at the highest level their license will allow, says Sinopoli. And many uncomplicated patients currently seen by doctors can be managed by a variety of physician extenders, he says, and more effectively and at a lower cost in a variety of settings.

But he says they should function “under the umbrella of a physician.”

“We don’t know that in the future that might not expand,” Sinopoli says. “But physicians go to school for 13 to 18 years to gain expertise. As we gain more experience with nurse practitioners and the scope of their practice gets more well-defined, there may be more comfort with them practicing totally independent.

“Now, that comfort level is not there.”

Meanwhile, efforts are under way to develop a curriculum that trains nurse practitioners for present-day needs, says Dr. Brenda Thames, vice president of academic development for GHS.

Producing more advanced practice nurses is one way to improve access, says Burgess, adding that about half of all nurse practitioners practice at a site without a physician now and half of all advanced practice nurses work in rural or underserved areas.

Last year, there were 2,253 advanced practice nurses in South Carolina and 1,282 of them were nurse practitioners, according to the White Paper.

Under the Affordable Care Act, hospitals will get $50 million a year from 2012 to 2015 to train advanced practice nurses, according to the Center for Studying Health System Change. It also reports that if the need for primary care doctors could be cut 25 percent by expanding the scope of practice for advanced practice nurses and physician assistants, about 75,000 fewer full-time-equivalent physicians would be needed.

Marling, who is dipping into savings to keep the lights on until her practice builds, says adding more nurse practitioners and expanding their scope of practice will improve access to care for everyone.

“There are more patients, but not enough physicians to see them,” she says. “We’d be such an asset.”